Inspection on 18/10/05 for Cedar Lodge

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cedar Lodge 10/12/08

Cedar Lodge 08/01/08

Cedar Lodge 26/06/07

Cedar Lodge 06/02/07

Cedar Lodge 16/05/06

Cedar Lodge 17/05/05

Cedar Lodge 27/10/04

Cedar Lodge 15/09/04

Cedar Lodge 18/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Red Lodge Care Home Hope Corner Lane Taunton Somerset TA2 7PB Lead Inspector Caroline Baker Announced 18 October 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Red Lodge Care Home Address Hope Corner Lane, Taunton, Somerset, TA2 7PB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 645325 N Notaro Homes Ltd Designate - Vivien Knighton PC Care home only 42 Category(ies) of Dementia - over 65 (42) registration, with number Old age (42) of places Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Registered for 42 persons in categories OP and DE(E). Numbers to include three service users between the ages of 55 and 65 years. Room 217 to used for ambulant independent service users only. Rooms 3 and 7 to only be used for service users with minimal moving and handling needs. Service users accommodated in rooms 201; 202; 203 must be continually assessed as to their mobility needs as these are only accessible via the stairs. Date of last inspection 17th May 2005 Brief Description of the Service: Red Lodge is a large, detached, extended property, set in good size grounds in a quiet residential area, approximately 1.5 miles from Taunton town centre. The home is Registered with the Commission for Social Care Inspection (CSCI) for up to 42 service users over the age of 65 years with mental health problems. Notaro Homes Ltd owns the home. The manager designate is Vivien knighton. Jill Camm Operations Manager is in close contact with the home. Mr Notaro is present at the home five days per week. Amenities are close at hand, including a Post Office, shops and pubs. There is inadequate parking provision at this time. Service user accommodation is on three floors. Bedrooms are found on all three floors, a lift gives access to all but 3 of the bedrooms, which are approached by a staircase. The home is in the process of being extended and refurbished to improve the environment and add a further 17 bedrooms - an application to register the new rooms has been received. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was unannounced on 17th May 2005. At that inspection five requirements were identified and four recommendations were made. This inspection was announced and took place over one day (16 inspector hours) by Kathy McCluskey and Caroline Baker. At the time of this inspection all of the requirements had been complied with two of the recommendations had been actioned. Thirty-nine service users were residing at the home and one was in hospital. Staffing levels appeared adequate on the day of inspection. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least seven service users were spoken with. Mr Notaro, the registered provider, was available. The manager designate was available throughout the inspection. The CSCI sent comment cards to service users, relatives/carers and health care professionals to gain their views on the conduct of the service. The home completed a pre-inspection questionnaire as part of the inspection process. Throughout the day the inspectors were able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. What the service does well: The service users looked well cared for, cheerful and happy. The provision of social activities is good. Comments received from service users including those via comment cards included: ‘I could not be in a better place’. ‘They are all kind and caring’ and ‘the food is good’. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 6 Comments received via comment cards from relatives/representatives of service users included: ‘My xxx appears happy with everything and is very comfortable with all the staff’ and ‘much help and support is shown to xxxx. Huge improvement in home environment. Overall very pleased with level of care’. The cleanliness of the home was very good and the home was well maintained. Staff looked professional and morale was good. What has improved since the last inspection? What they could do better: This inspection has identified issues in regard to: Care planning, lack of telephone facilities for service users, bedrooms not containing furniture and equipment identified in the homes Statement of Purpose, radiators being switched off and the warmth of some rooms, and the safety of service users whilst building works continue. The use of two un-commissioned new rooms identified breaches in regulations. A separate letter was sent to the provider identifying the CSCI’s concerns. Serious issues raised in regard to the receipt, recording and administration of medications led to an Immediate Requirement Notice being served, as findings put service users at risk of harm. The inspectors were satisfied that the manager acknowledged the seriousness of the findings at this inspection and that action will be taken to improve. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 7 The CSCI will continue to monitor the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, and 5. NMS 6 does not apply to the home. Prospective service users are provided with information to allow them to make an informed choice. The home takes appropriate steps to ensure the needs of prospective service users can be met prior to a decision being made about admission. EVIDENCE: The home had a Statement of Purpose and Service User Guide, which is available to prospective service users. The manager informed the inspectors that once the reception area was complete a Statement of Purpose would be displayed. The provider has applied to the CSCI to have the home registered as ‘Cedar Lodge’. Evidence was seen in the one of the six care records examined that a full preadmission assessment had been undertaken by the home to ensure it could meet individual service users needs prior to admission. Other assessments had been obtained from Social Services. The manager informed the inspectors that Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 10 she had recorded pre-assessments on two recent service users these were not seen at inspection. It was evident that the staff individually and collectively had the skills and experience to deliver the services and care which the home offers through staff training records seen. The majority of the staff had undertaken specialist training in dementia. Service users are able to visit the home prior to admission. The home provides day care for up to five persons from Monday to Friday. Some had gone on to have respite care on a regular basis. There were four persons receiving day care during this inspection. The manager informed the inspectors that staffing levels took day care into consideration. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Each service user had a care plan – those sampled were generally detailed and reflected individual current needs. Staff respected the privacy and dignity of service users. The new medication policy was comprehensive however the homes medication practices were generally poor and were found to put service users at risk of harm. EVIDENCE: On examination of six individual care plans and meeting the individual service users it was evident that the majority of current care needs were reflected. They were well written and contained detailed actions for care staff to be able to deliver the care. Individual risk assessments were in place in regards to falls, pressure areas, nutrition and manual handling. One care plan sampled did not contain a wound care plan or reflect the type of pressure relief used. Five did not contain life histories. Service users had not been weighed monthly or on admission according to the care plans. One care plan did not reflect next of kin details Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 12 and two did not reflect funeral details. Professional visit records were not always up to date, however were recorded in a separate folder in the new medical room. The home had a good support network with health care professionals. Comments received from GP’s and other health care professionals by the CSCI were overall very positive. However poor communication and having a quiet room for reviews, was raised as a concern and discussed with the manager. Comment cards received from service users all indicated that staff generally respected their privacy at the home. It was evident through indirect observation that staff treated the service users with respect and kindness. Service users able confirmed that the staff were kind and that they were given a choice of daily living. It was noted at this inspection that there are no appropriate telephone facilities for service user use. This is required. Service users are able to have their own telephone installed. As part of the inspection process medication systems were examined. As required at the last inspection the medication had been re-developed, was comprehensive and in line with current legislation. The inspector’s discovered however that staff were not following the policy. Findings raised serious concerns for the safety of the service users, which led to an Immediate Requirement Notice being issued. The findings were as follows: • • • • • Hand transcribed entries found on seven of the Medication Administration Records (MAR) sheets examined were not confirmed with two signatures. Medications had not been signed on receipt, the amount received recorded or dated on twenty of the MAR sheets examined. Doses admininistered for variable doses were not recorded on two MAR sheets examined. Hand transcribed Paracetamol did not indicate a maximum dose or indications on two occasions. Reasons for not administering prescribed medications were not recorded on five occasions. Gaps in signatures were noted on three occasions and ‘O’ was used without a definition on five occasions. Whilst auditing medicines as part of the case tracking process for two service users discrepancies in stocks of their prescribed medicines were D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 13 • Red Lodge Care Home noted. There were too many tablets left indicating they had been signed for and not given. These issues were brought to the attention of the manager and care supervisor who acknowledged the seriousness of the discrepancies and took action to ensure audits would be undertaken and that all staff responsible would be notified. All staff responsible for medication administration had received training in the safe handling of medication. The management should ensure that staff understand the training they have received and the seriousness of their omissions. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 15. The home’s arrangement for meeting service users social needs continues to improve. Friends and family can visit at any time. The routine of the home is dictated by the service users needs. Service users benefited from a varied diet. The dining room and service users were unsupervised before meals were served. EVIDENCE: At least seven service users were spoken to during the course of the inspection including five who were case tracked as part of the inspection process. All of the service users able stated that they were happy at the home. It was evident that a choice had been given to service users for the time they got up in the morning and how they chose to spend their day. The routine of the home appeared to be dictated by service users choice. The home had an activities co-ordinator and her hours had been increased since the last inspection. Social interests were seen recorded in the care plans examined. It was a pleasing to see service users either knitting, or playing Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 15 dominos. The atmosphere at the home was happy and relaxed. The service users in the main lounge were enjoying music. An activities record was kept and examined which highlighted one-one activities with those who could not join in. Flexercise is also part of the planned weekly activities. Service users able told inspectors that the food was good. The daily menu was posted up on a notice board. Menus appeared wholesome, varied and nutritious. The new kitchen was up and running. A new dining area is planned as part of the new build. Comments received from service users indicated that the majority of service users enjoyed the food. Comments were received in regard to waiting at the table for up to ½ hour at mealtimes for the food. This was confirmed at inspection and it was also noted that some service users became agitated. There were no members of staff supervising the dining room until the meals were served. A relative told inspectors that often during the wait service users start throwing drinking cups at each other. One service user again unsupervised, was once found in the kitchen, then in the dining room removing food from another’s plate and took another service users drink. Once brought to the attention of the manager a carer sat with the resident who became calm and ate their lunch. This must be monitored and the dining area always supervised. The manager informed the inspectors that she believed there would be an improvement once the new dining area was up and running. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system in place with evidence that views were appropriately acted upon. Steps had been taken to inform staff of the types of abuse to be aware of and the steps to take should they suspect abuse within the care home, however need to remind staff of outside agencies that can be contacted. EVIDENCE: The complaints procedure is found in the service user guide, which will be displayed once the reception area is completed. The home had received three complaints since the last inspection in regard to laundry going missing and a chair being used in the dining area. Appropriate action had been taken. Comment cards sent to relatives and service users indicated that 60 were aware of the complaints procedure and who to talk to should they be concerned. Action should be taken to ensure that all service users and their representatives are aware of the homes complaints procedures. Comments received from GP’s and Health Care Professionals indicated that they had not received any complaints about the home. The CSCI had not received any complaints about the home since the last inspection. The home had the multi-agency policy on Safeguarding Vulnerable Adults. The home had a Whistleblowing Policy, which is given to all staff as part of their induction. Abuse awareness training had been planned for July 2005 however appeared not to have taken place and this must be arranged. Staff spoken to Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 17 were aware of the types of abuse that could occur however were unsure of outside agencies to contact should they suspect any type of abuse occurring. Service users may access their personal financial records, if they wish to do, so at any time. The homes policies reflected this. Service users spoken to stated that they felt safe at the home. One member of staff had been referred to the POVA list since the last inspection following disciplinary action and dismissal, to protect vulnerable service users. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Service users live in a comfortable and generally safe environment, which appears able to meet the assessed needs of service users living there. Not all private service users rooms meet NMS and reflect the homes Statement of Purpose. The environment of the home has been improved and enhanced since the last inspection however there is a lack of ‘signage’ at the home causing confusion as to where certain areas are. Car parking is poor at this time due to building works. Service users could enjoy a safe walk in the enclosed garden at the front of the home. There were no malodours in the home; the standards of cleanliness were very good. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 19 EVIDENCE: Since the last inspection the whole home had been re-carpeted, refurbished and tastefully decorated to a high standard. The majority of bedrooms had been refurbished. Further walk in showers had been established and one bathroom had been changed into a medical/treatment room. There was a large new kitchen, a new reception area, administration office and manager’s office. The home had been decorated to provide an ‘enabling’ environment for those with dementia, including coloured doors for toilets and communal bathrooms. As discussed with the manager ‘signage’ should be used to allow service users and visitors to find their way around the home. The dining room was cramped at this inspection however the inspectors were satisfied that a further larger dining room is being provided in the near future. Many bedrooms assessed at this inspection did not have lockable spaces to enable service users to lock away any monies or valuables or bedside lamps as stated in the homes statement of purpose. One room was without an overhead light or lampshades and at least five rooms had their radiators turned off. One room had no handle on a wardrobe stopping the service user from accessing their clothes. One room was exposed to the place where staff and service users smoked allowing smoke into the room and compromising the individual service user’s privacy. These findings were brought to the attention of the manager who acknowledged the need for action to be taken. The provider has submitted an application to the CSCI to increase the provision at the home from 42 beds to 59 beds and change the name of the home to ‘Cedar Lodge’. During this inspection two of the new rooms were in use without agreement from the CSCI. This was discussed at the time of the inspection as they were not in line with the homes Statement of Purpose or NMS and had not been commissioned. The home had not increased its numbers and took action at inspection to remove one service user from an unsafe room. A separate letter was sent to the provider to confirm findings. All bedroom doors are alarmed and as discussed must be reflected in the Statement of Purpose and consent gained if there is an assessed need for use. Maintenance records had been recorded. The building complied with the local fire service and environmental health department according to records seen. The home was well ventilated on the day of inspection. Windows were restricted and radiators were guarded in line with HSE guidelines. Lighting is domestic in character. Hot water outlet temperature records were kept and were checked weekly. Bath hot water outlets checked were within safe limits. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 20 The cleanliness of the home at this inspection was very good. Infection Control systems were in place. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The home’s recruitment procedures for staff had improved. The numbers and skill mix of staff appeared appropriate to meet the needs of current service users. Many of the staff had enrolled to undertake NVQ training in care. Staff morale was good. EVIDENCE: Service users staff and relatives spoken to and able indicated that staffing levels were adequate at this time. Call bells heard were answered promptly. Service users looked well cared for and well attired. Staffing appeared adequate on the day of inspection. The home provides day care and staffing appears to have been taken into consideration of this. One service user needs one-one care and this was catered for. Staff spoken with indicated that staffing levels were appropriate to meet the current service users needs. The copies of duty rotas given to the inspectors indicated that minimum staffing levels had been maintained over the past two weeks. There had been three staff on duty overnight. Domestic hours appeared appropriate and given the cleanliness of the home it was evident that they were adequate. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 22 Six staff recruitment files were examined which evidenced good practice for the safety and protection of service users. Staff training records and speaking with staff and service users indicated that staff employed at the home are receiving training to ensure they are skilled and competent to do their job. Seven care staff were undertaking NVQ level 2 in care and six NVQ level 3 in care. Once completed the home will reach the target of 50 staff trained to NVQ or equivalent in care. The induction programme used for staff is being reviewed in line with the ‘Skills for Care’. As discussed any training given should be confirmed by the member of staff signing for receipt and their understanding of the training. Staff spoken to were happy at the home and felt that there was good morale amongst all the staff. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38. 32, 33, 34, 36, An application to register the manager designate is being processed by the CSCI. Staff were well supported by the management ethos. The home is committed to staff training. The systems in place for ensuring the health and safety of service users and staff are generally good. EVIDENCE: The manager designate is Vivien Knighton whose application to be registered with the CSCI to manage the home is being processed. Jill Camm operations manager and Mr Notaro provide support to the manager. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 24 The inspectors noted that improvement at the home continues in regard to the atmosphere, the care of the service users, the environment, and staff attitudes. Staff spoken to felt supported by the manager and indicated an improvement at the home over the past twelve months. Staff supervision had commenced; records were detailed and clear. There had not been any recent service user meetings or surveys distributed to gather views on the running of the home. This was recommended at the last inspection and will be further recommended with a time scale. The operations manager had recorded monthly Regulation 26 visits and copies had been sent to the CSCI. It is recommended that as part of these visits medication systems, and accidents are audited and bedrooms sampled to ensure they are in line with the homes Statement of Purpose. The majority of the records that were seen at this inspection were detailed, well maintained and up to date. The medication policy had been re-developed as previously mentioned. Staff spoken to were aware of the homes health and safety policies and had received mandatory training in fire awareness, infection control, moving and handling and health and safety. Food was stored correctly in the kitchen. Fridge and freezer temperature records were up to date. On assessment of the premises a linen room with exposed hot pipes was found unlocked. And a board to the building works was insecure when service users were wandering past putting them at risk. The board was secured during the inspection. All service histories were found to be up to date. Fire equipment servicing and recording of checks were up to date. PAT testing had been carried out in June 2005. Risk assessments had been carried out for all safe working practices and records were maintained. All accidents and injuries had been recorded. There were 40 recorded since the last inspection. Fourteen had resulted in attending A&E and two had resulted in a fracture. It was recommended at the last inspection that accidents be fully analysed monthly to identify any traits; this had not been done and is required at this inspection. There had been nine deaths in the past twelve months seven being in hospital. The CSCI has been informed of any serious incidents. Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 2 3 x 3 3 2 Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 and OP8 Regulation 15 and 17(1)[a] Schedule 3 13(2) and 17(1)[a] Schedule 3, 3{i} Timescale for action Individual service user care plans 30 must reflect: any wound care November needs, life histories, monthly 2005 weights, next of kin details and funeral details. The registered person must 18 October ensure that all staff responsible 2005 for the receipt, recording, and administration, of prescribed medications follow the homes medication policies. An Immediate Requirement Notice was issued. The registered person must ensure that telephone facilities are avaiable which are suitable for the assessed needs of service users, and make arrangements to enable service users to use such facilities in private. The Statement of Purpose (SOP) must reflect the fact that all bedroom doors are alarmed and all bedrooms must contain furnishings and be equipped as stated in the homes SOP. The registered person must ensure that all radiators are switched on and rooms are warm for service user comfort. Requirement 2. OP9 3. OP10 16(2)[b] .30 December 2005 4. OP24 16(2)[c] 30 November 2005 5. OP25 23(2)[p] 28 October 2005 Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 27 6. 7. OP38 OP38 13(4) 17(1)[a] Schedule 3 (j) The registered person must ensure the safety of service users at all times. The registered person must ensure accidents are analysed and audited on a monthly basis to identify any traits. 28 October 2005 30 December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations Communication between the home and health care professionals should be monitored and improved and a room should be provided for reviews where all those invloved would not be disturbed. The amount of time and provision of supervision before mealtimes should be reviewed and monitored in light of comments received from service users and relatives. Signage should be displayed at the home to allow service users and visitors to find their way around by end October 2005 The home should ensure that 50 of care staff are trained to NVQ in care by end of April 2006 The registered person should ensure that all staff training records carry a signature of the individual staff to confirm receipt and understanding. Quality Assurance surveys to service users and representatives should be implemented by April 2006. And Regualtion 26 visits should include, spot checking medications, bedrooms and accident records to ensure in line with the homes policies and NMS. 2. 3. 4. 5. 6. OP15 OP20 OP28 OP30 OP33 Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Red Lodge Care Home D53 - D02 59128 Red Lodge Care Home V245221 181005 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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